A Summary of Opioid Prescribing by Primary Care Providers: A Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns

            Pills, pills, pills. It’s a mad world out there these days. This article has been floating around social media in recent days. This study looks at prescribing patterns of primary care physicians, nurse practitioners (NPs), and physician assistants (PAs) to identify overprescribing. This retrospective, cross sectional analysis compared prescribing patterns of physicians, NPs, and PAs using 2015 Medicare claims data among 222,689 primary care providers. This stratified into 156,161 physicians; 42,655 NPs; and 23,873 PAs.

Based on the fact that physician and nonphysician prescribers differ in medical training, licensing, and recertification requirements, they hypothesized that:

“NPs and PAs would prescribe fewer opioids with a lower morphine milligram equivalents (MME)/ day than MDs. We further hypothesized that NPs/PAs in states without independent authority to prescribe schedule II opioids would prescribe opioids less frequently, with a lower MME/day, and for shorter periods than those in states with independent prescribing authority.”

            The purpose of the study is tied into providing evidence to reduce opioid prescribing by examining profiles of both physicians and nonphysician prescribers. The operative definition of over prescriber is a provider who met one of the following:

  1. prescribed any opioid to > 50% of patients,
  2. prescribed ≥ 100 morphine milligram equivalents (MME)/ day to > 10% of patients, or
  3. prescribed an opioid > 90 days to > 20% of patient

Results include 3.8% of physicians, 8.0% of NPs, and 9.8% of PAs met at least one definition of overprescribing. 1.3% of physicians, 6.3% of NPs, and 8.8% of PAs prescribed an opioid to at least 50% of patients. NPs/PAs practicing in states with independent prescription authority were > 20 times more likely to overprescribe opioids than NPs/PAs in prescription restricted states.

            The study found that after adjusting for patient comorbidity in the multivariable analyses, compared with physicians, NPs/PAs were more likely to prescribe high frequency (OR: NP, 2.26; PA, 4.36) and high-dose opioids (OR: NP, 1.29; PA, 1.62), but less likely to prescribe longterm opioids (OR: NP, 0.51; PA, 0.60).

            As per the study discussion, more NPs/PAs than physicians were outliers who prescribed high frequency (any opioid to >50% of patients) or high-dose opioids (> 100 MME/day to >10% of patients. NPs/ PAs in states with independent prescription authority for schedule II opioids were more likely to overprescribe opioids than NPs/PAs in states with restricted prescription authority.  The article referenced studies (which I will look at in a different time) that indicate emerging data that NPs/PAs as a group prescribe more opioids than physicians. The article also referenced studies that reported generalist NPs/PAs prescribe a disproportionately high quantity of opioids compared with physicians and that NPs/PAs significantly increased opioid prescribing from 2013 to 2017, a period when almost every medical specialty decreased opioid prescribing.

            The article reported on prior research that showed an effect of state policy on overprescribing where other studies reported that state scope of practice legislation did not predict opioid prescribing. This study supported research on NP/PA opioid prescribing by describing the frequency/potency/duration of prescriptions and by showing the effect of state policy on overprescribing. In states that granted independent prescription authority, 7.5% of NPs and 10.0% of PAs were high-frequency opioid prescribers. In states which restricted authority, only 0.18% of NPs and 0.74% of PAs were high frequency prescribers.

Our findings of high NP/PA overprescribing in states with independent prescription authority suggest that restricting NPs/PAs prescribing authority might reduce opioid overprescribing.

            Limitations of the study include that data was only from 2015; that palliative care could confound results; limited analysis to 20% sample data set; that overprescribing is inconsistently defined in previous literature. 

Conclusions include:

  1. that primary care NPs and PAs prescribed these opioids more often and at higher doses than did primary care physicians,
  2. that 8.0% of NPs and 9.8% of PAs met at least one definition of opioid overprescribing compared with 3.8% of physicians,
  3. that in states that allowed NPs/PAs to independently prescribe schedule II controlled substances, NPs/PAs were > 20 times more likely to overprescribe opioids than in states with restricted prescription authority.

That being said, I’ll leave it there. 

Reference:

  1. M JL, Raji MA, Goodwin JS, Kuo Y-F. Opioid Prescribing by Primary Care Providers: a Cross-Sectional Analysis of Nurse Practitioner, Physician Assistant, and Physician Prescribing Patterns. Journal of General Internal Medicine. 2020;1–9.

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